Documentation requirements
reasonable_and_necessary
other
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 36222 | HCPCS | Covered |
| 36223 | HCPCS | Covered |
| 36224 | HCPCS | Covered |
| 36225 | HCPCS | Covered |
| 36226 | HCPCS | Covered |
| 36227 | HCPCS | Covered |
| 36228 | HCPCS | Covered |
| C41.2 | ICD10CM | Covered |
| C69.01 | ICD10CM | Covered |
| C69.02 | ICD10CM | Covered |
| C69.11 | ICD10CM | Covered |
| C69.12 | ICD10CM | Covered |
| C69.21 | ICD10CM | Covered |
| C69.22 | ICD10CM | Covered |
| C69.31 | ICD10CM | Covered |
| C69.32 | ICD10CM | Covered |
| C69.41 | ICD10CM | Covered |
| C69.42 | ICD10CM | Covered |
| C69.51 | ICD10CM | Covered |
| C69.52 | ICD10CM | Covered |
| C69.61 | ICD10CM | Covered |
| C69.62 | ICD10CM | Covered |
| C69.81 | ICD10CM | Covered |
| C69.82 | ICD10CM | Covered |
| C69.91 | ICD10CM | Covered |
| C69.92 | ICD10CM | Covered |
| C70.0 | ICD10CM | Covered |
| C70.1 | ICD10CM | Covered |
| C71.0 | ICD10CM | Covered |
| C71.1 | ICD10CM | Covered |
| C71.2 | ICD10CM | Covered |
| C71.3 | ICD10CM | Covered |
| C71.4 | ICD10CM | Covered |
| C71.5 | ICD10CM | Covered |
| C71.6 | ICD10CM | Covered |
| C71.7 | ICD10CM | Covered |
| C71.8 | ICD10CM | Covered |
| C71.9 | ICD10CM | Covered |
| C72.0 | ICD10CM | Covered |
| C72.1 | ICD10CM | Covered |
| C72.21 | ICD10CM | Covered |
| C72.22 | ICD10CM | Covered |
| C72.31 | ICD10CM | Covered |
| C72.32 | ICD10CM | Covered |
| C72.41 | ICD10CM | Covered |
| C72.42 | ICD10CM | Covered |
| C72.50 | ICD10CM | Covered |
| C72.59 | ICD10CM | Covered |
| C72.9 | ICD10CM | Covered |
| C73 | ICD10CM | Covered |
| C75.0 | ICD10CM | Covered |
| C75.1 | ICD10CM | Covered |
| C75.2 | ICD10CM | Covered |
| C75.3 | ICD10CM | Covered |
| C75.4 | ICD10CM | Covered |
| C79.31 | ICD10CM | Covered |
| C79.32 | ICD10CM | Covered |
| C79.40 | ICD10CM | Covered |
| C79.49 | ICD10CM | Covered |
| D18.02 | ICD10CM | Covered |
| D18.09 | ICD10CM | Covered |
| D32.0 | ICD10CM | Covered |
| D32.9 | ICD10CM | Covered |
| D33.0 | ICD10CM | Covered |
| D33.1 | ICD10CM | Covered |
| D33.2 | ICD10CM | Covered |
| D33.3 | ICD10CM | Covered |
| D35.2 | ICD10CM | Covered |
| D35.3 | ICD10CM | Covered |
| D42.0 | ICD10CM | Covered |
| D42.1 | ICD10CM | Covered |
| D43.0 | ICD10CM | Covered |
| D43.1 | ICD10CM | Covered |
| D43.2 | ICD10CM | Covered |
| D43.4 | ICD10CM | Covered |
| D44.3 | ICD10CM | Covered |
| D44.4 | ICD10CM | Covered |
| D44.5 | ICD10CM | Covered |
| D44.6 | ICD10CM | Covered |
| D44.7 | ICD10CM | Covered |
| D49.6 | ICD10CM | Covered |
| E22.0 | ICD10CM | Covered |
| E22.1 | ICD10CM | Covered |
| E22.2 | ICD10CM | Covered |
| E22.8 | ICD10CM | Covered |
| E22.9 | ICD10CM | Covered |
| E23.0 | ICD10CM | Covered |
| E23.1 | ICD10CM | Covered |
| E23.2 | ICD10CM | Covered |
| E23.6 | ICD10CM | Covered |
| E24.1 | ICD10CM | Covered |
| E34.4 | ICD10CM | Covered |
| E89.3 | ICD10CM | Covered |
| G08 | ICD10CM | Covered |
| G40.001 | ICD10CM | Covered |
| G40.009 | ICD10CM | Covered |
| G40.011 | ICD10CM | Covered |
| G40.019 | ICD10CM | Covered |
| G40.101 | ICD10CM | Covered |
| G40.109 | ICD10CM | Covered |
| G40.111 | ICD10CM | Covered |
| G40.119 | ICD10CM | Covered |
| G40.201 | ICD10CM | Covered |
| G40.209 | ICD10CM | Covered |
| G40.211 | ICD10CM | Covered |
| G40.219 | ICD10CM | Covered |
| G40.301 | ICD10CM | Covered |
| G40.309 | ICD10CM | Covered |
| G40.311 | ICD10CM | Covered |
| G40.319 | ICD10CM | Covered |
| G40.401 | ICD10CM | Covered |
| G40.409 | ICD10CM | Covered |
| G40.411 | ICD10CM | Covered |
| G40.419 | ICD10CM | Covered |
| G40.501 | ICD10CM | Covered |
| G40.509 | ICD10CM | Covered |
| G40.801 | ICD10CM | Covered |
| G40.802 | ICD10CM | Covered |
| G40.803 | ICD10CM | Covered |
| G40.804 | ICD10CM | Covered |
| G40.811 | ICD10CM | Covered |
| G40.812 | ICD10CM | Covered |
| G40.813 | ICD10CM | Covered |
| G40.814 | ICD10CM | Covered |
| G40.821 | ICD10CM | Covered |
| G40.822 | ICD10CM | Covered |
| G40.823 | ICD10CM | Covered |
| G40.824 | ICD10CM | Covered |
| G40.89 | ICD10CM | Covered |
| G40.A01 | ICD10CM | Covered |
| G40.A09 | ICD10CM | Covered |
| G40.A11 | ICD10CM | Covered |
| G40.A19 | ICD10CM | Covered |
| G40.B01 | ICD10CM | Covered |
| G40.B09 | ICD10CM | Covered |
| G40.B11 | ICD10CM | Covered |
| G40.B19 | ICD10CM | Covered |
| G45.0 | ICD10CM | Covered |
| G45.1 | ICD10CM | Covered |
| G45.2 | ICD10CM | Covered |
| G45.3 | ICD10CM | Covered |
| G45.8 | ICD10CM | Covered |
| G45.9 | ICD10CM | Covered |
| G46.0 | ICD10CM | Covered |
| G46.1 | ICD10CM | Covered |
| G46.2 | ICD10CM | Covered |
| G50.0 | ICD10CM | Covered |
| G54.0 | ICD10CM | Covered |
| G81.01 | ICD10CM | Covered |
| G81.02 | ICD10CM | Covered |
| G81.03 | ICD10CM | Covered |
| G81.04 | ICD10CM | Covered |
| G81.11 | ICD10CM | Covered |
| G81.12 | ICD10CM | Covered |
| G81.13 | ICD10CM | Covered |
| G81.14 | ICD10CM | Covered |
| G81.91 | ICD10CM | Covered |
| G81.92 | ICD10CM | Covered |
| G81.93 | ICD10CM | Covered |
| G81.94 | ICD10CM | Covered |
| G95.11 | ICD10CM | Covered |
| G95.19 | ICD10CM | Covered |
| G97.31 | ICD10CM | Covered |
| G97.32 | ICD10CM | Covered |
| H34.01 | ICD10CM | Covered |
| H34.02 | ICD10CM | Covered |
| H34.03 | ICD10CM | Covered |
| H34.11 | ICD10CM | Covered |
| H34.12 | ICD10CM | Covered |
| H34.13 | ICD10CM | Covered |
| H34.211 | ICD10CM | Covered |
| H34.212 | ICD10CM | Covered |
| H34.213 | ICD10CM | Covered |
| H34.231 | ICD10CM | Covered |
| H34.232 | ICD10CM | Covered |
| H34.233 | ICD10CM | Covered |
| H34.8110 | ICD10CM | Covered |
| H34.8111 | ICD10CM | Covered |
| H34.8120 | ICD10CM | Covered |
| H34.8121 | ICD10CM | Covered |
| H34.8130 | ICD10CM | Covered |
| H34.8131 | ICD10CM | Covered |
| H34.821 | ICD10CM | Covered |
| H34.822 | ICD10CM | Covered |
| H34.823 | ICD10CM | Covered |
| H34.8310 | ICD10CM | Covered |
| H34.8311 | ICD10CM | Covered |
| H34.8320 | ICD10CM | Covered |
| H34.8321 | ICD10CM | Covered |
| H34.8330 | ICD10CM | Covered |
| H34.8331 | ICD10CM | Covered |
| H34.9 | ICD10CM | Covered |
| H35.071 | ICD10CM | Covered |
| H35.072 | ICD10CM | Covered |
| H35.073 | ICD10CM | Covered |
| H49.01 | ICD10CM | Covered |
| H49.02 | ICD10CM | Covered |
| H49.03 | ICD10CM | Covered |
| H49.11 | ICD10CM | Covered |
| H49.12 | ICD10CM | Covered |
| H49.13 | ICD10CM | Covered |
| H49.21 | ICD10CM | Covered |
| H49.22 | ICD10CM | Covered |
| H49.23 | ICD10CM | Covered |
| H49.31 | ICD10CM | Covered |
| H49.32 | ICD10CM | Covered |
| H49.33 | ICD10CM | Covered |
| H49.41 | ICD10CM | Covered |
| H49.42 | ICD10CM | Covered |
| H49.43 | ICD10CM | Covered |
| H49.881 | ICD10CM | Covered |
| H49.882 | ICD10CM | Covered |
| H49.883 | ICD10CM | Covered |
| H49.9 | ICD10CM | Covered |
| H53.121 | ICD10CM | Covered |
| H53.122 | ICD10CM | Covered |
| H53.123 | ICD10CM | Covered |
| H53.461 | ICD10CM | Covered |
| H53.462 | ICD10CM | Covered |
| H53.47 | ICD10CM | Covered |
| H53.71 | ICD10CM | Covered |
| H53.72 | ICD10CM | Covered |
| H53.8 | ICD10CM | Covered |
| I60.01 | ICD10CM | Covered |
| I60.02 | ICD10CM | Covered |
| I60.11 | ICD10CM | Covered |
| I60.12 | ICD10CM | Covered |
| I60.2 | ICD10CM | Covered |
| I60.31 | ICD10CM | Covered |
| I60.32 | ICD10CM | Covered |
| I60.4 | ICD10CM | Covered |
| I60.51 | ICD10CM | Covered |
| I60.52 | ICD10CM | Covered |
| I60.6 | ICD10CM | Covered |
| I60.7 | ICD10CM | Covered |
| I60.8 | ICD10CM | Covered |
| I60.9 | ICD10CM | Covered |
| I61.0 | ICD10CM | Covered |
| I61.1 | ICD10CM | Covered |
| I61.2 | ICD10CM | Covered |
| I61.3 | ICD10CM | Covered |
| I61.4 | ICD10CM | Covered |
| I61.5 | ICD10CM | Covered |
| I61.6 | ICD10CM | Covered |
| I61.8 | ICD10CM | Covered |
| I61.9 | ICD10CM | Covered |
| I62.00 | ICD10CM | Covered |
| I62.01 | ICD10CM | Covered |
| I62.02 | ICD10CM | Covered |
| I62.03 | ICD10CM | Covered |
| I62.1 | ICD10CM | Covered |
| I62.9 | ICD10CM | Covered |
| I63.011 | ICD10CM | Covered |
| I63.012 | ICD10CM | Covered |
| I63.013 | ICD10CM | Covered |
| I63.02 | ICD10CM | Covered |
| I63.031 | ICD10CM | Covered |
| I63.032 | ICD10CM | Covered |
| I63.033 | ICD10CM | Covered |
| I63.09 | ICD10CM | Covered |
| I63.111 | ICD10CM | Covered |
| I63.112 | ICD10CM | Covered |
| I63.113 | ICD10CM | Covered |
| I63.12 | ICD10CM | Covered |
| I63.131 | ICD10CM | Covered |
| I63.132 | ICD10CM | Covered |
| I63.133 | ICD10CM | Covered |
| I63.19 | ICD10CM | Covered |
| I63.211 | ICD10CM | Covered |
| I63.212 | ICD10CM | Covered |
| I63.213 | ICD10CM | Covered |
| I63.22 | ICD10CM | Covered |
| I63.231 | ICD10CM | Covered |
| I63.232 | ICD10CM | Covered |
| I63.233 | ICD10CM | Covered |
| I63.30 | ICD10CM | Covered |
| I63.311 | ICD10CM | Covered |
| I63.312 | ICD10CM | Covered |
| I63.313 | ICD10CM | Covered |
| I63.321 | ICD10CM | Covered |
| I63.322 | ICD10CM | Covered |
| I63.323 | ICD10CM | Covered |
| I63.331 | ICD10CM | Covered |
| I63.332 | ICD10CM | Covered |
| I63.333 | ICD10CM | Covered |
| I63.341 | ICD10CM | Covered |
| I63.342 | ICD10CM | Covered |
| I63.343 | ICD10CM | Covered |
| I63.39 | ICD10CM | Covered |
| I63.40 | ICD10CM | Covered |
| I63.411 | ICD10CM | Covered |
| I63.412 | ICD10CM | Covered |
| I63.413 | ICD10CM | Covered |
| I63.421 | ICD10CM | Covered |
| I63.422 | ICD10CM | Covered |
| I63.423 | ICD10CM | Covered |
| I63.431 | ICD10CM | Covered |
| I63.432 | ICD10CM | Covered |
| I63.433 | ICD10CM | Covered |
| I63.441 | ICD10CM | Covered |
| I63.442 | ICD10CM | Covered |
| I63.443 | ICD10CM | Covered |
| I63.49 | ICD10CM | Covered |
| I63.511 | ICD10CM | Covered |
| I63.512 | ICD10CM | Covered |
| I63.513 | ICD10CM | Covered |
| I63.521 | ICD10CM | Covered |
| I63.522 | ICD10CM | Covered |
| I63.523 | ICD10CM | Covered |
| I63.531 | ICD10CM | Covered |
| I63.532 | ICD10CM | Covered |
| I63.533 | ICD10CM | Covered |
| I63.541 | ICD10CM | Covered |
| I63.542 | ICD10CM | Covered |
| I63.543 | ICD10CM | Covered |
| I63.59 | ICD10CM | Covered |
| I63.6 | ICD10CM | Covered |
| I63.81 | ICD10CM | Covered |
| I63.89 | ICD10CM | Covered |
| I63.9 | ICD10CM | Covered |
| I65.01 | ICD10CM | Covered |
| I65.02 | ICD10CM | Covered |
| I65.03 | ICD10CM | Covered |
| I65.1 | ICD10CM | Covered |
| I65.21 | ICD10CM | Covered |
| I65.22 | ICD10CM | Covered |
| I65.23 | ICD10CM | Covered |
| I65.8 | ICD10CM | Covered |
| I66.01 | ICD10CM | Covered |
| I66.02 | ICD10CM | Covered |
| I66.03 | ICD10CM | Covered |
| I66.11 | ICD10CM | Covered |
| I66.12 | ICD10CM | Covered |
| I66.13 | ICD10CM | Covered |
| I66.21 | ICD10CM | Covered |
| I66.22 | ICD10CM | Covered |
| I66.23 | ICD10CM | Covered |
| I66.3 | ICD10CM | Covered |
| I66.8 | ICD10CM | Covered |
| I66.9 | ICD10CM | Covered |
| I67.1 | ICD10CM | Covered |
| I67.5 | ICD10CM | Covered |
| I67.6 | ICD10CM | Covered |
| I67.7 | ICD10CM | Covered |
| I67.81 | ICD10CM | Covered |
| I67.82 | ICD10CM | Covered |
| I67.841 | ICD10CM | Covered |
| I67.848 | ICD10CM | Covered |
| I67.89 | ICD10CM | Covered |
| I68.2 | ICD10CM | Covered |
| I71.010 | ICD10CM | Covered |
| I71.011 | ICD10CM | Covered |
| I71.012 | ICD10CM | Covered |
| I71.019 | ICD10CM | Covered |
| I71.03 | ICD10CM | Covered |
| I71.10 | ICD10CM | Covered |
| I71.11 | ICD10CM | Covered |
| I71.12 | ICD10CM | Covered |
| I71.13 | ICD10CM | Covered |
| I71.20 | ICD10CM | Covered |
| I71.21 | ICD10CM | Covered |
| I71.22 | ICD10CM | Covered |
| I71.23 | ICD10CM | Covered |
| I71.50 | ICD10CM | Covered |
| I71.51 | ICD10CM | Covered |
| I71.52 | ICD10CM | Covered |
| I71.60 | ICD10CM | Covered |
| I71.61 | ICD10CM | Covered |
| I71.62 | ICD10CM | Covered |
| I72.0 | ICD10CM | Covered |
| I72.5 | ICD10CM | Covered |
| I72.6 | ICD10CM | Covered |
| I72.8 | ICD10CM | Covered |
| I74.11 | ICD10CM | Covered |
| I74.2 | ICD10CM | Covered |
| I77.1 | ICD10CM | Covered |
| I77.74 | ICD10CM | Covered |
| I77.75 | ICD10CM | Covered |
| I97.810 | ICD10CM | Covered |
| I97.811 | ICD10CM | Covered |
| I97.820 | ICD10CM | Covered |
| I97.821 | ICD10CM | Covered |
| M30.0 | ICD10CM | Covered |
| M30.1 | ICD10CM | Covered |
| M30.2 | ICD10CM | Covered |
| M30.8 | ICD10CM | Covered |
| M31.2 | ICD10CM | Covered |
| M31.30 | ICD10CM | Covered |
| M31.31 | ICD10CM | Covered |
| M31.5 | ICD10CM | Covered |
| M31.6 | ICD10CM | Covered |
| M31.7 | ICD10CM | Covered |
| Q25.21 | ICD10CM | Covered |
| Q25.29 | ICD10CM | Covered |
| Q25.3 | ICD10CM | Covered |
| Q25.40 | ICD10CM | Covered |
| Q25.41 | ICD10CM | Covered |
| Q25.42 | ICD10CM | Covered |
| Q25.43 | ICD10CM | Covered |
| Q25.44 | ICD10CM | Covered |
| Q25.45 | ICD10CM | Covered |
| Q25.46 | ICD10CM | Covered |
| Q25.47 | ICD10CM | Covered |
| Q25.48 | ICD10CM | Covered |
| Q25.49 | ICD10CM | Covered |
| Q25.6 | ICD10CM | Covered |
| Q25.72 | ICD10CM | Covered |
| Q25.79 | ICD10CM | Covered |
| Q27.31 | ICD10CM | Covered |
| Q27.39 | ICD10CM | Covered |
| Q28.2 | ICD10CM | Covered |
| Q28.3 | ICD10CM | Covered |
| Q28.8 | ICD10CM | Covered |
| R04.0 | ICD10CM | Covered |
| R04.1 | ICD10CM | Covered |
| R04.2 | ICD10CM | Covered |
| R04.81 | ICD10CM | Covered |
| R04.89 | ICD10CM | Covered |
| R04.9 | ICD10CM | Covered |
| R47.01 | ICD10CM | Covered |
| R56.9 | ICD10CM | Covered |
| R90.82 | ICD10CM | Covered |
| R93.0 | ICD10CM | Covered |
| R93.89 | ICD10CM | Covered |
| S01.90XA | ICD10CM | Covered |
| S06.0X0A | ICD10CM | Covered |
| S06.0X0D | ICD10CM | Covered |
| S06.0X0S | ICD10CM | Covered |
| S06.1X0A | ICD10CM | Covered |
| S06.1X0D | ICD10CM | Covered |
| S06.1X0S | ICD10CM | Covered |
| S06.1X1A | ICD10CM | Covered |
| S06.1X1D | ICD10CM | Covered |
| S06.1X1S | ICD10CM | Covered |
| S06.1X2A | ICD10CM | Covered |
| S06.1X2D | ICD10CM | Covered |
| S06.1X2S | ICD10CM | Covered |
| S06.1X3A | ICD10CM | Covered |
| S06.1X3D | ICD10CM | Covered |
| S06.1X3S | ICD10CM | Covered |
| S06.1X4A | ICD10CM | Covered |
| S06.1X4D | ICD10CM | Covered |
| S06.1X4S | ICD10CM | Covered |
| S06.1X5A | ICD10CM | Covered |
| S06.1X5D | ICD10CM | Covered |
| S06.1X5S | ICD10CM | Covered |
| S06.1X6A | ICD10CM | Covered |
| S06.1X6D | ICD10CM | Covered |
| S06.1X6S | ICD10CM | Covered |
| S06.1X9A | ICD10CM | Covered |
| S06.1X9D | ICD10CM | Covered |
| S06.1X9S | ICD10CM | Covered |
| S06.2X0A | ICD10CM | Covered |
| S06.2X0D | ICD10CM | Covered |
| S06.2X0S | ICD10CM | Covered |
| S06.2X1A | ICD10CM | Covered |
| S06.2X1D | ICD10CM | Covered |
| S06.2X1S | ICD10CM | Covered |
| S06.2X2A | ICD10CM | Covered |
| S06.2X2D | ICD10CM | Covered |
| S06.2X2S | ICD10CM | Covered |
| S06.2X3A | ICD10CM | Covered |
| S06.2X3D | ICD10CM | Covered |
| S06.2X3S | ICD10CM | Covered |
| S06.2X4A | ICD10CM | Covered |
| S06.2X4D | ICD10CM | Covered |
| S06.2X4S | ICD10CM | Covered |
| S06.2X5A | ICD10CM | Covered |
| S06.2X5D | ICD10CM | Covered |
| S06.2X5S | ICD10CM | Covered |
| S06.2X6A | ICD10CM | Covered |
| S06.2X6D | ICD10CM | Covered |
| S06.2X6S | ICD10CM | Covered |
| S06.2X9A | ICD10CM | Covered |
| S06.2X9D | ICD10CM | Covered |
| S06.2X9S | ICD10CM | Covered |
| S06.300A | ICD10CM | Covered |
| S06.300D | ICD10CM | Covered |
| S06.300S | ICD10CM | Covered |
| S06.301A | ICD10CM | Covered |
| S06.301D | ICD10CM | Covered |
| S06.301S | ICD10CM | Covered |
| S06.302A | ICD10CM | Covered |
| S06.302D | ICD10CM | Covered |
| S06.302S | ICD10CM | Covered |
| S06.303A | ICD10CM | Covered |
| S06.303D | ICD10CM | Covered |
| S06.303S | ICD10CM | Covered |
| S06.304A | ICD10CM | Covered |
| S06.304D | ICD10CM | Covered |
| S06.304S | ICD10CM | Covered |
| S06.305A | ICD10CM | Covered |
| S06.305D | ICD10CM | Covered |
| S06.305S | ICD10CM | Covered |
| S06.306A | ICD10CM | Covered |
| S06.306D | ICD10CM | Covered |
| S06.306S | ICD10CM | Covered |
| S06.309A | ICD10CM | Covered |
| S06.309D | ICD10CM | Covered |
| S06.309S | ICD10CM | Covered |
| S06.340A | ICD10CM | Covered |
| S06.340D | ICD10CM | Covered |
| S06.340S | ICD10CM | Covered |
| S06.341A | ICD10CM | Covered |
| S06.341D | ICD10CM | Covered |
| S06.341S | ICD10CM | Covered |
| S06.342A | ICD10CM | Covered |
| S06.342D | ICD10CM | Covered |
| S06.342S | ICD10CM | Covered |
| S06.343A | ICD10CM | Covered |
| S06.343D | ICD10CM | Covered |
| S06.343S | ICD10CM | Covered |
| S06.344A | ICD10CM | Covered |
| S06.344D | ICD10CM | Covered |
| S06.344S | ICD10CM | Covered |
| S06.345A | ICD10CM | Covered |
| S06.345D | ICD10CM | Covered |
| S06.345S | ICD10CM | Covered |
| S06.346A | ICD10CM | Covered |
| S06.346D | ICD10CM | Covered |
| S06.346S | ICD10CM | Covered |
| S06.349A | ICD10CM | Covered |
| S06.349D | ICD10CM | Covered |
| S06.349S | ICD10CM | Covered |
| S06.350A | ICD10CM | Covered |
| S06.350D | ICD10CM | Covered |
| S06.350S | ICD10CM | Covered |
| S06.351A | ICD10CM | Covered |
| S06.351D | ICD10CM | Covered |
| S06.351S | ICD10CM | Covered |
| S06.352A | ICD10CM | Covered |
| S06.352D | ICD10CM | Covered |
| S06.352S | ICD10CM | Covered |
| S06.353A | ICD10CM | Covered |
| S06.353D | ICD10CM | Covered |
| S06.353S | ICD10CM | Covered |
| S06.354A | ICD10CM | Covered |
| S06.354D | ICD10CM | Covered |
| S06.354S | ICD10CM | Covered |
| S06.355A | ICD10CM | Covered |
| S06.355D | ICD10CM | Covered |
| S06.355S | ICD10CM | Covered |
| S06.356A | ICD10CM | Covered |
| S06.356D | ICD10CM | Covered |
| S06.356S | ICD10CM | Covered |
| S06.359A | ICD10CM | Covered |
| S06.359D | ICD10CM | Covered |
| S06.359S | ICD10CM | Covered |
| S06.360A | ICD10CM | Covered |
| S06.360D | ICD10CM | Covered |
| S06.360S | ICD10CM | Covered |
| S06.361A | ICD10CM | Covered |
| S06.361D | ICD10CM | Covered |
| S06.361S | ICD10CM | Covered |
| S06.362A | ICD10CM | Covered |
| S06.362D | ICD10CM | Covered |
| S06.362S | ICD10CM | Covered |
| S06.363A | ICD10CM | Covered |
| S06.363D | ICD10CM | Covered |
| S06.363S | ICD10CM | Covered |
| S06.364A | ICD10CM | Covered |
| S06.364D | ICD10CM | Covered |
| S06.364S | ICD10CM | Covered |
| S06.365A | ICD10CM | Covered |
| S06.365D | ICD10CM | Covered |
| S06.365S | ICD10CM | Covered |
| S06.366A | ICD10CM | Covered |
| S06.366D | ICD10CM | Covered |
| S06.366S | ICD10CM | Covered |
| S06.369A | ICD10CM | Covered |
| S06.369D | ICD10CM | Covered |
| S06.369S | ICD10CM | Covered |
| S06.4X0A | ICD10CM | Covered |
| S06.4X0D | ICD10CM | Covered |
| S06.4X0S | ICD10CM | Covered |
| S06.4X1A | ICD10CM | Covered |
| S06.4X1D | ICD10CM | Covered |
| S06.4X1S | ICD10CM | Covered |
| S06.4X2A | ICD10CM | Covered |
| S06.4X2D | ICD10CM | Covered |
| S06.4X2S | ICD10CM | Covered |
| S06.4X3A | ICD10CM | Covered |
| S06.4X3D | ICD10CM | Covered |
| S06.4X3S | ICD10CM | Covered |
| S06.4X4A | ICD10CM | Covered |
| S06.4X4D | ICD10CM | Covered |
| S06.4X4S | ICD10CM | Covered |
| S06.4X5A | ICD10CM | Covered |
| S06.4X5D | ICD10CM | Covered |
| S06.4X5S | ICD10CM | Covered |
| S06.4X6A | ICD10CM | Covered |
| S06.4X6D | ICD10CM | Covered |
| S06.4X6S | ICD10CM | Covered |
| S06.4X9A | ICD10CM | Covered |
| S06.4X9D | ICD10CM | Covered |
| S06.4X9S | ICD10CM | Covered |
| S06.5X0A | ICD10CM | Covered |
| S06.5X0D | ICD10CM | Covered |
| S06.5X0S | ICD10CM | Covered |
| S06.5X1A | ICD10CM | Covered |
| S06.5X1D | ICD10CM | Covered |
| S06.5X1S | ICD10CM | Covered |
| S06.5X2A | ICD10CM | Covered |
| S06.5X2D | ICD10CM | Covered |
| S06.5X2S | ICD10CM | Covered |
| S06.5X3A | ICD10CM | Covered |
| S06.5X3D | ICD10CM | Covered |
| S06.5X3S | ICD10CM | Covered |
| S06.5X4A | ICD10CM | Covered |
| S06.5X4D | ICD10CM | Covered |
| S06.5X4S | ICD10CM | Covered |
| S06.5X5A | ICD10CM | Covered |
| S06.5X5D | ICD10CM | Covered |
| S06.5X5S | ICD10CM | Covered |
| S06.5X6A | ICD10CM | Covered |
| S06.5X6D | ICD10CM | Covered |
| S06.5X6S | ICD10CM | Covered |
| S06.5X9A | ICD10CM | Covered |
| S06.5X9D | ICD10CM | Covered |
| S06.5X9S | ICD10CM | Covered |
| S06.6X0A | ICD10CM | Covered |
| S06.6X0D | ICD10CM | Covered |
| S06.6X0S | ICD10CM | Covered |
| S06.6X1A | ICD10CM | Covered |
| S06.6X1D | ICD10CM | Covered |
| S06.6X1S | ICD10CM | Covered |
| S06.6X2A | ICD10CM | Covered |
| S06.6X2D | ICD10CM | Covered |
| S06.6X2S | ICD10CM | Covered |
| S06.6X3A | ICD10CM | Covered |
| S06.6X3D | ICD10CM | Covered |
| S06.6X3S | ICD10CM | Covered |
| S06.6X4A | ICD10CM | Covered |
| S06.6X4D | ICD10CM | Covered |
| S06.6X4S | ICD10CM | Covered |
| S06.6X5A | ICD10CM | Covered |
| S06.6X5D | ICD10CM | Covered |
| S06.6X5S | ICD10CM | Covered |
| S06.6X6A | ICD10CM | Covered |
| S06.6X6D | ICD10CM | Covered |
| S06.6X6S | ICD10CM | Covered |
| S06.6X9A | ICD10CM | Covered |
| S06.6X9D | ICD10CM | Covered |
| S06.6X9S | ICD10CM | Covered |
| S06.810A | ICD10CM | Covered |
| S06.810D | ICD10CM | Covered |
| S06.810S | ICD10CM | Covered |
| S06.811A | ICD10CM | Covered |
| S06.811D | ICD10CM | Covered |
| S06.811S | ICD10CM | Covered |
| S06.812A | ICD10CM | Covered |
| S06.812D | ICD10CM | Covered |
| S06.812S | ICD10CM | Covered |
| S06.813A | ICD10CM | Covered |
| S06.813D | ICD10CM | Covered |
| S06.813S | ICD10CM | Covered |
| S06.814A | ICD10CM | Covered |
| S06.814D | ICD10CM | Covered |
| S06.814S | ICD10CM | Covered |
| S06.815A | ICD10CM | Covered |
| S06.815D | ICD10CM | Covered |
| S06.815S | ICD10CM | Covered |
| S06.816A | ICD10CM | Covered |
| S06.816D | ICD10CM | Covered |
| S06.816S | ICD10CM | Covered |
| S06.819A | ICD10CM | Covered |
| S06.819D | ICD10CM | Covered |
| S06.819S | ICD10CM | Covered |
| S06.820A | ICD10CM | Covered |
| S06.820D | ICD10CM | Covered |
| S06.820S | ICD10CM | Covered |
| S06.821A | ICD10CM | Covered |
| S06.821D | ICD10CM | Covered |
| S06.821S | ICD10CM | Covered |
| S06.822A | ICD10CM | Covered |
| S06.822D | ICD10CM | Covered |
| S06.822S | ICD10CM | Covered |
| S06.823A | ICD10CM | Covered |
| S06.823D | ICD10CM | Covered |
| S06.823S | ICD10CM | Covered |
| S06.824A | ICD10CM | Covered |
| S06.824D | ICD10CM | Covered |
| S06.824S | ICD10CM | Covered |
| S06.825A | ICD10CM | Covered |
| S06.825D | ICD10CM | Covered |
| S06.825S | ICD10CM | Covered |
| S06.826A | ICD10CM | Covered |
| S06.826D | ICD10CM | Covered |
| S06.826S | ICD10CM | Covered |
| S06.829A | ICD10CM | Covered |
| S06.829D | ICD10CM | Covered |
| S06.829S | ICD10CM | Covered |
| S06.890A | ICD10CM | Covered |
| S06.890D | ICD10CM | Covered |
| S06.890S | ICD10CM | Covered |
| S06.891A | ICD10CM | Covered |
| S06.891D | ICD10CM | Covered |
| S06.891S | ICD10CM | Covered |
| S06.892A | ICD10CM | Covered |
| S06.892D | ICD10CM | Covered |
| S06.892S | ICD10CM | Covered |
| S06.893A | ICD10CM | Covered |
| S06.893D | ICD10CM | Covered |
| S06.893S | ICD10CM | Covered |
| S06.894A | ICD10CM | Covered |
| S06.894D | ICD10CM | Covered |
| S06.894S | ICD10CM | Covered |
| S06.895A | ICD10CM | Covered |
| S06.895D | ICD10CM | Covered |
| S06.895S | ICD10CM | Covered |
| S06.896A | ICD10CM | Covered |
| S06.896D | ICD10CM | Covered |
| S06.896S | ICD10CM | Covered |
| S06.899A | ICD10CM | Covered |
| S06.899D | ICD10CM | Covered |
| S06.899S | ICD10CM | Covered |
| S06.9X9A | ICD10CM | Covered |
| S06.9X9D | ICD10CM | Covered |
| S06.9X9S | ICD10CM | Covered |
| S09.0XXA | ICD10CM | Covered |
| S09.0XXD | ICD10CM | Covered |
| S09.0XXS | ICD10CM | Covered |
| S15.001A | ICD10CM | Covered |
| S15.001D | ICD10CM | Covered |
| S15.001S | ICD10CM | Covered |
| S15.002A | ICD10CM | Covered |
| S15.002D | ICD10CM | Covered |
| S15.002S | ICD10CM | Covered |
| S15.011A | ICD10CM | Covered |
| S15.011D | ICD10CM | Covered |
| S15.011S | ICD10CM | Covered |
| S15.012A | ICD10CM | Covered |
| S15.012D | ICD10CM | Covered |
| S15.012S | ICD10CM | Covered |
| S15.021A | ICD10CM | Covered |
| S15.021D | ICD10CM | Covered |
| S15.021S | ICD10CM | Covered |
| S15.022A | ICD10CM | Covered |
| S15.022D | ICD10CM | Covered |
| S15.022S | ICD10CM | Covered |
| S15.091A | ICD10CM | Covered |
| S15.091D | ICD10CM | Covered |
| S15.091S | ICD10CM | Covered |
| S15.092A | ICD10CM | Covered |
| S15.092D | ICD10CM | Covered |
| S15.092S | ICD10CM | Covered |
| S15.101A | ICD10CM | Covered |
| S15.101D | ICD10CM | Covered |
| S15.101S | ICD10CM | Covered |
| S15.102A | ICD10CM | Covered |
| S15.102D | ICD10CM | Covered |
| S15.102S | ICD10CM | Covered |
| S15.111A | ICD10CM | Covered |
| S15.111D | ICD10CM | Covered |
| S15.111S | ICD10CM | Covered |
| S15.112A | ICD10CM | Covered |
| S15.112D | ICD10CM | Covered |
| S15.112S | ICD10CM | Covered |
| S15.121A | ICD10CM | Covered |
| S15.121D | ICD10CM | Covered |
| S15.121S | ICD10CM | Covered |
| S15.122A | ICD10CM | Covered |
| S15.122D | ICD10CM | Covered |
| S15.122S | ICD10CM | Covered |
| S15.191A | ICD10CM | Covered |
| S15.191D | ICD10CM | Covered |
| S15.191S | ICD10CM | Covered |
| S15.192A | ICD10CM | Covered |
| S15.192D | ICD10CM | Covered |
| S15.192S | ICD10CM | Covered |
| S15.201A | ICD10CM | Covered |
| S15.201D | ICD10CM | Covered |
| S15.201S | ICD10CM | Covered |
| S15.202A | ICD10CM | Covered |
| S15.202D | ICD10CM | Covered |
| S15.202S | ICD10CM | Covered |
| S15.211A | ICD10CM | Covered |
| S15.211D | ICD10CM | Covered |
| S15.211S | ICD10CM | Covered |
| S15.212A | ICD10CM | Covered |
| S15.212D | ICD10CM | Covered |
| S15.212S | ICD10CM | Covered |
| S15.221A | ICD10CM | Covered |
| S15.221D | ICD10CM | Covered |
| S15.221S | ICD10CM | Covered |
| S15.222A | ICD10CM | Covered |
| S15.222D | ICD10CM | Covered |
| S15.222S | ICD10CM | Covered |
| S15.291A | ICD10CM | Covered |
| S15.291D | ICD10CM | Covered |
| S15.291S | ICD10CM | Covered |
| S15.292A | ICD10CM | Covered |
| S15.292D | ICD10CM | Covered |
| S15.292S | ICD10CM | Covered |
| S15.301A | ICD10CM | Covered |
| S15.301D | ICD10CM | Covered |
| S15.301S | ICD10CM | Covered |
| S15.302A | ICD10CM | Covered |
| S15.302D | ICD10CM | Covered |
| S15.302S | ICD10CM | Covered |
| S15.311A | ICD10CM | Covered |
| S15.311D | ICD10CM | Covered |
| S15.311S | ICD10CM | Covered |
| S15.312A | ICD10CM | Covered |
| S15.312D | ICD10CM | Covered |
| S15.312S | ICD10CM | Covered |
| S15.321A | ICD10CM | Covered |
| S15.321D | ICD10CM | Covered |
| S15.321S | ICD10CM | Covered |
| S15.322A | ICD10CM | Covered |
| S15.322D | ICD10CM | Covered |
| S15.322S | ICD10CM | Covered |
| S15.391A | ICD10CM | Covered |
| S15.391D | ICD10CM | Covered |
| S15.391S | ICD10CM | Covered |
| S15.392A | ICD10CM | Covered |
| S15.392D | ICD10CM | Covered |
| S15.392S | ICD10CM | Covered |
| S15.8XXA | ICD10CM | Covered |
| S15.8XXD | ICD10CM | Covered |
| S15.8XXS | ICD10CM | Covered |
| S15.9XXA | ICD10CM | Covered |
| S15.9XXD | ICD10CM | Covered |
| S15.9XXS | ICD10CM | Covered |
| S25.00XA | ICD10CM | Covered |
| S25.00XD | ICD10CM | Covered |
| S25.00XS | ICD10CM | Covered |
| S25.01XA | ICD10CM | Covered |
| S25.01XD | ICD10CM | Covered |
| S25.01XS | ICD10CM | Covered |
| S25.02XA | ICD10CM | Covered |
| S25.02XD | ICD10CM | Covered |
| S25.02XS | ICD10CM | Covered |
| S25.09XA | ICD10CM | Covered |
| S25.09XD | ICD10CM | Covered |
| S25.09XS | ICD10CM | Covered |
| S25.101A | ICD10CM | Covered |
| S25.101D | ICD10CM | Covered |
| S25.101S | ICD10CM | Covered |
| S25.102A | ICD10CM | Covered |
| S25.102D | ICD10CM | Covered |
| S25.102S | ICD10CM | Covered |
| S25.111A | ICD10CM | Covered |
| S25.111D | ICD10CM | Covered |
| S25.111S | ICD10CM | Covered |
| S25.112A | ICD10CM | Covered |
| S25.112D | ICD10CM | Covered |
| S25.112S | ICD10CM | Covered |
| S25.121A | ICD10CM | Covered |
| S25.121D | ICD10CM | Covered |
| S25.121S | ICD10CM | Covered |
| S25.122A | ICD10CM | Covered |
| S25.122D | ICD10CM | Covered |
| S25.122S | ICD10CM | Covered |
| S25.191A | ICD10CM | Covered |
| S25.191D | ICD10CM | Covered |
| S25.191S | ICD10CM | Covered |
| S25.192A | ICD10CM | Covered |
| S25.192D | ICD10CM | Covered |
| S25.192S | ICD10CM | Covered |
| S48.011A | ICD10CM | Covered |
| S48.011D | ICD10CM | Covered |
| S48.011S | ICD10CM | Covered |
| S48.012A | ICD10CM | Covered |
| S48.012D | ICD10CM | Covered |
| S48.012S | ICD10CM | Covered |
| S48.021A | ICD10CM | Covered |
| S48.021D | ICD10CM | Covered |
| S48.021S | ICD10CM | Covered |
| S48.022A | ICD10CM | Covered |
| S48.022D | ICD10CM | Covered |
| S48.022S | ICD10CM | Covered |
| S48.111A | ICD10CM | Covered |
| S48.111D | ICD10CM | Covered |
| S48.111S | ICD10CM | Covered |
| S48.112A | ICD10CM | Covered |
| S48.112D | ICD10CM | Covered |
| S48.112S | ICD10CM | Covered |
| S48.121A | ICD10CM | Covered |
| S48.121D | ICD10CM | Covered |
| S48.121S | ICD10CM | Covered |
| S48.122A | ICD10CM | Covered |
| S48.122D | ICD10CM | Covered |
| S48.122S | ICD10CM | Covered |
| S48.911A | ICD10CM | Covered |
| S48.911D | ICD10CM | Covered |
| S48.911S | ICD10CM | Covered |
| S48.912A | ICD10CM | Covered |
| S48.912D | ICD10CM | Covered |
| S48.912S | ICD10CM | Covered |
| S48.921A | ICD10CM | Covered |
| S48.921D | ICD10CM | Covered |
| S48.921S | ICD10CM | Covered |
| S48.922A | ICD10CM | Covered |
| S48.922D | ICD10CM | Covered |
| S48.922S | ICD10CM | Covered |
| T82.311A | ICD10CM | Covered |
| T82.311D | ICD10CM | Covered |
| T82.311S | ICD10CM | Covered |
| T82.321A | ICD10CM | Covered |
| T82.321D | ICD10CM | Covered |
| T82.321S | ICD10CM | Covered |
| T82.331A | ICD10CM | Covered |
| T82.331D | ICD10CM | Covered |
| T82.331S | ICD10CM | Covered |
| T82.391A | ICD10CM | Covered |
| T82.391D | ICD10CM | Covered |
| T82.391S | ICD10CM | Covered |
| T82.510A | ICD10CM | Covered |
| T82.510D | ICD10CM | Covered |
| T82.510S | ICD10CM | Covered |
| T82.511A | ICD10CM | Covered |
| T82.511D | ICD10CM | Covered |
| T82.511S | ICD10CM | Covered |
| T82.513A | ICD10CM | Covered |
| T82.513D | ICD10CM | Covered |
| T82.513S | ICD10CM | Covered |
| T82.514A | ICD10CM | Covered |
| T82.514D | ICD10CM | Covered |
| T82.514S | ICD10CM | Covered |
| T82.515A | ICD10CM | Covered |
| T82.515D | ICD10CM | Covered |
| T82.515S | ICD10CM | Covered |
| T82.518A | ICD10CM | Covered |
| T82.518D | ICD10CM | Covered |
| T82.518S | ICD10CM | Covered |
| T82.520A | ICD10CM | Covered |
| T82.520D | ICD10CM | Covered |
| T82.520S | ICD10CM | Covered |
| T82.521A | ICD10CM | Covered |
| T82.521D | ICD10CM | Covered |
| T82.521S | ICD10CM | Covered |
| T82.523A | ICD10CM | Covered |
| T82.523D | ICD10CM | Covered |
| T82.523S | ICD10CM | Covered |
| T82.524A | ICD10CM | Covered |
| T82.524D | ICD10CM | Covered |
| T82.524S | ICD10CM | Covered |
| T82.525A | ICD10CM | Covered |
| T82.525D | ICD10CM | Covered |
| T82.525S | ICD10CM | Covered |
| T82.528A | ICD10CM | Covered |
| T82.528D | ICD10CM | Covered |
| T82.528S | ICD10CM | Covered |
| T82.529A | ICD10CM | Covered |
| T82.529D | ICD10CM | Covered |
| T82.529S | ICD10CM | Covered |
| T82.530A | ICD10CM | Covered |
| T82.530D | ICD10CM | Covered |
| T82.530S | ICD10CM | Covered |
| T82.531A | ICD10CM | Covered |
| T82.531D | ICD10CM | Covered |
| T82.531S | ICD10CM | Covered |
| T82.532A | ICD10CM | Covered |
| T82.532D | ICD10CM | Covered |
| T82.532S | ICD10CM | Covered |
| T82.533A | ICD10CM | Covered |
| T82.533D | ICD10CM | Covered |
| T82.533S | ICD10CM | Covered |
| T82.534A | ICD10CM | Covered |
| T82.534D | ICD10CM | Covered |
| T82.534S | ICD10CM | Covered |
| T82.538A | ICD10CM | Covered |
| T82.538D | ICD10CM | Covered |
| T82.538S | ICD10CM | Covered |
| T82.590A | ICD10CM | Covered |
| T82.590D | ICD10CM | Covered |
| T82.590S | ICD10CM | Covered |
| T82.591A | ICD10CM | Covered |
| T82.591D | ICD10CM | Covered |
| T82.591S | ICD10CM | Covered |
| T82.593A | ICD10CM | Covered |
| T82.593D | ICD10CM | Covered |
| T82.593S | ICD10CM | Covered |
| T82.594A | ICD10CM | Covered |
| T82.594D | ICD10CM | Covered |
| T82.594S | ICD10CM | Covered |
| T82.595A | ICD10CM | Covered |
| T82.595D | ICD10CM | Covered |
| T82.595S | ICD10CM | Covered |
| T82.598A | ICD10CM | Covered |
| T82.598D | ICD10CM | Covered |
| T82.598S | ICD10CM | Covered |